Insurance Fraud is one of the top challenges that insurers are facing worldwide. While there are pricing pressures owing to slow economic environment, cutting back the Claims payout is one of the best means to increase efficiency and cut cost. From a strategic perspective also, carriers overall success to a large extent depends on the manner they treat their Claims function; for many insurers Claim processing efficiency is often their unique selling proposition. Reducing Claim leakages by effectively fighting against insurance Fraud and having a larger focus on recovery management can help insurers reduce their Claim cost.
This article is an effort to highlight five key areas that should be considered when building an effective Fraud management strategy.
1. Underwriting Prudence
Claims and Fraud management begin much before the Claim incident is reported. There are several indicators that can raise suspicion during the underwriting process. After the Claims are settled, the Claims data can positively impact the underwriting and rating functions. There is a need to incorporate more information into the underwriting decision-making process. The responsible use of data and information during the underwriting analysis is one of the most powerful weapons against Fraud.
The organization should know its prospective customers well to find fraudulent intentions beginning the review of sales proposal. An attempt should be made to dig deeper to verify identity and every application must be individually scrutinized. The goal of reducing Claim leakages should be kept in mind from the very beginning and the Fraud fighting mechanism should be activated from that moment.
2. FNOL Management
From a Fraud perspective, effective management of First Notice of Loss (FNOL) process is crucial for the insurance company. Through improved workflow, streamlining the processes and use of automation, insurers can identify the Fraud triggers and recovery possibilities early in the Claims cycle. The insurers should make use of early warning systems like, Voice Analytics for timely identification of Fraud. There are key factors for example, who reports the Claim (Claimant vs. Attorney Vs. anyone else); the time when the Claim is reported (Immediate vs. Delayed reporting); and the manner in which Claim is reported that can raise suspicion on the genuineness of the loss.
Any delay in identifying the Fraud triggers can have serious consequences later. If the decision to make an SIU appointment is late, the insurers can lose important eyewitness that can affect the Fraud analysis and the recovery possibilities. Any time lost during this stage will cause more than four times efforts, time and cost in the future. To fight the Fraud in an efficient manner, insurers have to be wiser and faster in comparison to Fraudsters. The use Data Analytics to narrow the possible number of Claims to be investigated for Fraud is vital. The insurers can then pay attention to those Claims, where high probability of Fraud exists.
3. Developing an Effective Claims Team
Effective deployment of resources is an important part of the overall Fraud management. Any organization that wants to effectually handle Fraud, must rebuild the Fraud investigative skills and capabilities. It should hire people with solid investigative skills to build a strong SIU unit for Fraud handling. By virtue of their experience, investigators who have worked for the FBI, Police and other investigative agencies can bring more value to the table.
The employees should be equipped with the necessary resources and a well-defined training program should exist. There should be online education and awareness programs through an Online Claims monitor on recent Fraud to the Claim handlers and investigators. Claims people should encourage feedback from the Claimants as a quality improvement tool. There should be a seamless link between Claims personnel and underwriters to make sure the overall business perspective is maintained and followed.
The aging of the baby boomers and the lack of skillful resources is resulting in heavy reliance on automation and investment in IT. Management should have a well-defined strategy to retain employees with key skills through the workload and work-life balancing. The goal of containing Claim leakages and rebuilding investigation skills and capabilities cannot be met unless the organization has a well laid out and forward-looking re-sourcing strategy.
4. Use of Technology
One of the problems being faced by Claims Organizations these days is the increased use of manual processes with limited use of tools and technology to manage processes. It is often found that the Claims Division in an insurance organization is one of the departments that are working with less-than optimal systems with huge maintenance cost. The need of Advanced Technology and Analytics in the Fraud handling cannot be over emphasized. The insurers should develop an integrated Fraud program with full policy life cycle consideration having clear defined Fraud management goals that are aligned to the business model.
With the number of people using social media sites, increasing day by day, the insurers should even consider social network analysis. The integration of Claims systems with social networking sites can prove to be an effective tool for Fraud detection. For insurers where the fraud leakage is on the higher side, it can even consider integration of IT systems with outside law enforcement agencies’ like the FBI, Interpol and DMV. The automation of the decision-making process based on business rules can also help in streamlining and standardizing the Claims process.
5. Information Sharing
Often it is found that different functional areas within an insurance organization do not talk well with each other. Thus, there is a greater need to strengthen data sharing between various departments specially, Underwriting, Claims and Finance. There might be similar Fraud patterns and issues across other lines of business, like Workers’ Comp, Commercial Auto and Crime. Having access to look across different coverage types for common behavior will be critical to success when combating Fraud. Besides, the companies should collectively work towards the maintenance of Fraud databases to have all the information in one place. This can aid in the analysis of Fraudulent Claim by comparing with old Frauds and grow the institutional knowledge and capabilities of the Fraud management.
There should be a centralized Fraud module where the findings and reports from Claim handlers and investigators are documented and available for anytime review. With Fraudsters becoming more sophisticated in their approach, there is a greater need for increasing industry collaboration and sharing of leading practices among insurers to combat Fraud.